Children’s Crossing Pediatric Dentistry
76 E Commerce Drive Suite 100
Saratoga Springs, UT 84045
Date:____________
Patient Information
Name: ___________________________________________ Preferred Name: ________________
Date of Birth: __________________ Age: _____
Male / Female
Height: ______ Weight: _____ Phone #: __________________
Address: _______________________________________ City: ___________________ State: ______ Zip: ________
Whom may we thank for referring you to our office? ____________________________________________________
Parent’s Marital Status:
_____ Married
______ Single
______ Divorced
______Widowed
Tell us about your Child’s Dental History
Why did you bring your child to the dentist today?_______________________________________________________
Is this your child’s first dental visit? Yes No Name of previous dentist: ____________________ Last visit date______
How do you think your child will behave today? (Check all that may apply)
___ friendly
___ happy
___ anxious
___ timid
___ afraid
___ resistant
Has your child ever has a serious/difficult problem associated with previous dental work?
Is your child’s water fluoridated? Yes
No
___ combative
Yes
No
Is your child taking fluoride supplements? Yes
No
Does your child brush his/her teeth daily? Yes
No
Floss daily? Yes
No
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)? Yes
Are you happy with the appearance of your child’s teeth? Yes No
No
Explain if no ____________________________
Does your child have any of the following habits?
Y N
Lip Sucking/Biting
Y
N
Nail Biting
Y
N
Nursing/Bottle Habits
Y
N
Thumb/Finger Sucking
Tell us about your Child’s Medical History
Has your child had a history or difficulty with any of the following? If yes to any, please describe below.
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
Abnormal Bleeding
Any Blood Disease or Anemia
Allergies to any drugs (list below)
Asthma
Brain Injury
Cancer or Malignancies
Cerebral Palsy
Congenital Heart Defect
Convulsions/Epilepsy
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
Diabetes
Eye, Ear, Nose, Throat Problems
Gag Reflex
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV/AIDS
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
Kidney/Liver Problems
Mental or Learning Delay
Other Heart Ailment
Premature Birth
Rheumatic Fever
Speech Disorder
Tuberculosis (TB)
Tumors or Growths
Other, explain below
If Heart Condition present, does your child require an antibiotic premed prior to having certain procedures done? Yes / No
Name of child’s physician __________________________________________ Phone #: __________________________
Is your child under doctor’s care now? Yes No For what reason?___________________________________________
Please list all drugs or medications your child is currently taking: _____________________________________________
Has your child had any serious medical problems? ________________________________________________________
Has your child ever been hospitalized and/or had operations? Yes No
Reason: ______________________________
Please list all drugs your child is allergic to: ______________________________________________________________
If you answered yes to any questions above, please give any additional information necessary. ______________
_________________________________________________________________________________________
__________________________________________________________________________________________